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ANDERSON SCHOOL DISTRICT FIVE

School Volunteer Form

TO BE COMPLETED BY ALL VOLUNTEERS HAVING A SUPERVISORY ROLE WITH STUDENTS.

PRINT ALL RESPONSES USING BLUE OR BLACK INK

First Name

Middle Name

Last Name

Maiden Name

Address

City

State

Zip Code

Gender (circle)

Race

Phone #’s

(H)

(W)

(C)

Date of Birth

Month

Day

Year

Area(s) in which you are a volunteer: Please check below all that apply

I AM INTERESTED IN BEING

SCHOOL VOLUNTEER

CHAPERONE

TUTOR

MENTOR (COMPLETE PAGE 2)

OTHER

Have you served in one of our schools before? (circle) YES NO

If YES, which school(s) __________________________________________________________________________________

Child’s Name_____________________________________________________________ Grade________________________

Anderson School District Five promises to provide a safe, nurturing environment for our students. We respectfully request that all volunteers having a supervisory role with students complete a background check. All of our school employees do this at time of hire. All background check information is confidential and is kept in accordance with state, federal and local regulations. Thank you so much for helping our students and our schools!

Signature: _______________________________________________ Date: _______________________________________

School(s) Requested: ___________________________________________________________________________________

Principal’s Signature: ___________________________________________________________________________________

ANDERSON SCHOOL DISTRICT FIVE

MENTOR BACKGROUND CHECK

PERSONAL INFORMATION RELEASE FORM

Last Name	First Name	Middle Name

Current Street Address	City	State	Zip Code
E-Mail Address

Please list any additional addresses residences in the last 7 years (most current first).


Street Address	City	State	Zip Code

Street Address	City	State	Zip Code

Would you prefer to be matched with a male student or female student? £ Male £ Female £ No Preference

What grade level of child do you prefer? K-2 _____ 3-5 _____ 6-8 _____ 9-12 _____

What special skills do you feel you have to offer a young person? __________________________________________________________________________________________________________________________________________________________________________________________________________

For the protection of our children, we ask you to respond to the following questions. Thanks for understanding.

Have you ever been charged with and/or convicted of a criminal offense? YES ___ NO ___

If YES, please explain in detail: __________________________________________________________________________

_____________________________________________________________________________________________________

Have you ever been investigated, charged, or convicted of child abuse, neglect or any other offense involving a child?

YES ___ NO ___ If YES, please explain in detail: ___________________________________________________________

_____________________________________________________________________________________________________

If you have a school preference, please name the school: _____________________________________________________

By signing below, you are authorizing Anderson School District Five to secure any and all personal information from any source of record that they deem necessary in order to perform a background check on you. You further authorize and release District Five from legal liability for collecting and reporting your personal background information.

All background check information is confidential and is kept in accordance with state, federal and local regulations. Thank you so much for helping our students and our schools!

_____________________________________________ _________________________________________

Mentor Applicant Signature Date

When completed, please return to: Tripp Dukes, Assistant Superintendent, P.O. Box 439, Anderson, SC 29622 or fax to 864-260-4463.

Policy

Dear Volunteer,

Please read the Anderson School District Five Policy on Staff Conduct. Sign below indicating that you have read and understand this policy. This form should be returned to the volunteer coordinator.

STAFF CONDUCT

Code GBEB Issued 7/03

Purpose: To establish the board's vision for appropriate staff conduct.

The board reaffirms one of the oldest beliefs in education: One of the best methods of instruction is that of setting a good example.

The board expects the staff of the district to strive to set the kind of example for students that will serve them well in their own conduct and behavior and subsequently contribute to an appropriate school atmosphere.

To that end, in dress, conduct and interpersonal relationships, all staff should recognize that they are being continuously observed by students and that their actions and demeanor will be reflected in the conduct of the students. The administration shall establish an administrative rule implementing the expectation that staff members dress in a professional manner.

The personal life of an employee will be the concern of and warrant the attention of the board only as it may directly prevent the employee from effectively performing assigned functions during duty hours or as it violates local, state or federal law or contractual agreements.

Adopted 9/18/01; Revised 7/29/03

Signature

Date

Anderson County School District Five